What are the common drugs used to treat Chronic Kidney Disease (CKD) in pediatric patients?

Common Drugs for Chronic Kidney Disease in Pediatric Patients

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are the first-line medications for pediatric CKD, especially in the presence of hypertension and/or proteinuria. 1

First-Line Medications

ACE Inhibitors

• Lisinopril
  • Starting dose: 0.07 mg/kg once daily (up to 5 mg total) for children ≥6 years with GFR >30 mL/min/1.73m² 2
  • Maximum dose: 0.61 mg/kg (up to 40 mg) once daily 2
  • Not recommended in children <6 years or with GFR <30 mL/min/1.73m² 2
• Enalapril
  • Commonly used in pediatric CKD, particularly effective for proteinuria 3
  • Typical dose range: 0.2-0.56 mg/kg/day 3

Angiotensin Receptor Blockers (ARBs)

• Losartan
  • Starting dose: 0.7 mg/kg once daily (up to 50 mg total) 4
  • Maximum dose: 1.4 mg/kg (up to 100 mg) daily 4
  • Not recommended in children <6 years or with GFR <30 mL/min/1.73m² 4

Indications for ACEi/ARB Use in Pediatric CKD

1. Hypertension

   • Start antihypertensive treatment when BP is consistently above the 90th percentile for age, sex, and height 1
   • Target BP: 24-hour mean arterial pressure ≤50th percentile on ambulatory BP monitoring 1
   • When ABPM is not available, target manual office systolic BP of 50th-75th percentile 1

2. Proteinuria

   • ACEi or ARBs are recommended for children with CKD and proteinuria regardless of the level 1, 5
   • These medications have shown significant improvement in renal survival in proteinuric children 6

Important Considerations

• Monitoring: Check serum creatinine, potassium, and BP within 2-4 weeks of initiation or dose increase 1
• Caution: Continue ACEi/ARB unless serum creatinine rises by more than 30% within 4 weeks of starting treatment 1
• Contraindications: Pregnancy, hyperkalemia, bilateral renal artery stenosis
• Protein intake: Do not restrict protein intake in children with CKD due to risk of growth impairment 1
• Sodium intake: Follow age-based recommended daily intake for sodium in children with CKD and hypertension 1

Combination Therapy vs. Monotherapy

• Single therapy with maximum doses of ACEi or ARB should be tried first 1
• Combination therapy (ACEi + ARB) may provide additional antiproteinuric effects in selected cases 7, 3
• However, dual RAAS blockade is generally not recommended due to increased risk of hyperkalemia and acute kidney injury 1
• Consider combination therapy only in selected patients with persistent proteinuria despite maximum doses of single agents 7, 8

Second-Line Medications

When ACEi/ARB therapy is insufficient or contraindicated:

• Calcium Channel Blockers

  • Long-acting formulations preferred
  • Use with caution as some studies in ADPKD showed potential to promote cyst growth 1

• Diuretics

  • Use with caution as they may increase vasopressin levels and potentially worsen GFR 1
  • May be necessary for volume control in advanced CKD

• Beta-Blockers

  • Not recommended as initial treatment due to expanded adverse effect profile 1
  • May be used as add-on therapy when necessary

Special Considerations for Different CKD Etiologies

• Autosomal Dominant Polycystic Kidney Disease (ADPKD)

  • ACEi/ARBs are first-line therapy 1
  • Avoid calcium channel blockers if possible due to potential cyst growth promotion 1
  • Avoid diuretics if possible due to potential vasopressin elevation 1

• Proteinuric Nephropathies

  • ACEi/ARBs have shown to achieve proteinuria remission in a substantial proportion of children 7
  • Remission of proteinuria is associated with kidney function stabilization or improvement 7

Remember that early intervention with appropriate medications can significantly improve long-term outcomes in pediatric CKD by slowing disease progression and reducing complications.